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Clinical Characteristics

There are no identifiable symptoms related to the penetration of the human intestine by the larvae early in the life cycle of the guinea worm. Its development in the retroperitoneal and other deeper tissues is likewise clinically silent. However, the migration of the mature, gravid female can cause generalized allergic phenomena, including urticaria, fever, asthma, vomiting, malaise, giddiness and severe pruritus, associated with moderate eosinophilia. These symptoms are usually most severe several hours before the worm appears beneath the skin surface and they subside once a blister has developed and larvae are discharged. There may be severe itching or burning as the head and anterior portion of the worm reach the skin surface and a blister develops. The body of the worm may be felt in the subcutaneous tissues as an erythematous, tender, raised, serpiginous cord (this is most likely the fiery serpent referred to in ancient times). A severe cellulitis or abscess may develop if the head of the worm is avulsed by injudicious attempts at removal. In endemic areas, such as West and Central Africa, dracunculiasis should be considered in the differential diagnosis of any inflammatory skin or subcutaneous swelling, especially in the lower limbs.

The scrotum may be inflamed at times with occasional associated hydrocele. In other ectopic sites, the raised, serpentine outline of the worm beneath the skin allows the clinician to make the diagnosis. If a tract is not present, the diagnosis may remain obscure until the typical blister develops with discharge of a milky fluid containing larvae. Guinea worm is frequently seen about the head, neck, and shoulder girdle in individuals living in areas where water or basins of wet bricks or sand are carried on the head. In those areas where water skins are commonly carried on the back, the worm preferentially comes to the surface over the back or pelvic girdle, where it is most likely to find moisture. Extradural abscesses or granulomas with spinal cord compression caused by ectopic migration of a guinea worm have been reported, but are rare. Tetanus is an uncommon but serious complication in some patients with dracunculiasis.

When a migrating worm dies close to a joint, a reactionary effusion develops which may progress to a septic arthritis and ankylosis, usually of the knee or ankle, but any major joint can be affected. In one study of 20 Saudi and Yemeni patients with calcified guinea worms who presented with various rheumatic manifestations, 55% had localized myalgia, 35% chronic monoarthralgia, and 10% chronic synovitis of the knee.

The correct clinical diagnosis may not be established by the physician or surgeon in patients where the necrotizing fluid expelled from the uterus of a dying or dead worm initiates a localized cyst or abscess in the soft tissues (Fig. 27.10). These lesions may vary in size from 2-12 cm and usually appear 2-4 years after the onset of dracunculiasis. They can occur anywhere between or in the muscles and may lead to serious complications such as myositis or septic arthritis. Davey 's book, Companion to Surgery in Africa, pages 90-93, gives an excellent discussion of these guinea worm cysts and abscesses.

Fig. 27.10 A-C Guinea worm cysts in the region of the knee, upper thigh and groin of three different African patients. (From W.W. Davey: Companion to Surgery in Africa, E & S Livingstone, London, 1968).

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